On 28th of March 2013 | commenced an investigation into the death of Mark Stephen Smith aged 52 years old_ The investigation concluded at the end of the inquest on 16th October 2013 The conclusion of the inquest was a narrative conclusion Mark Smith having died of Zopiclone and Mirtazapine overdose complicated by ethanol use with chronic obstructive pulmonary disease and coronary artery atheroma under paragraph 2 On the 2nd March 2013 Mr Smith telephoned for an ambulance having intentionally taken more of his medication than the dose prescribed by his doctors There was a delay from 8.57 and 53 seconds; when an ambulance should have reached Mr Smith, to 11.18 and 17 seconds when the ambulance arrived to assist Mr Smith_ This reezay was the result of a recognised mismatch between capability and demand and on the March 2013 between 3am and Zpm there were 15 and 20 ambulances short pan-London: This was likely to have contributed to Mr Smith's death:

Following Mr Smith's call to the London Ambulance Service the Emergency Medical Despatcher obtained the correct determinant for the response ,(a response under 30 minutes). When a call a person threatening suicide and who is alone, as Mr Smith was; the instruction within the operating procedure OPO8O is that the fact that the caller is alone should be documented and the Emergency Medical Despatcher should stay on the line with them where possible: Emergency Medical Despatcher did not note that Mr Smith was alone and did not stay on the line with Mr Smith Had _these steps been taken it may_have been possible to the Day delay taking from The recognise at an earlier stage when Mr Smith; who, although the Emergency Medical Despatcher did not know this, had taken medication that would render him unconscious within 30 to 45 minutes_ This significance of this would be that had Mr Smith fallen unconscious and the Emergency Medical Despatcher had known this the call would have been upgraded to a response within 8 minutes_

In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action: